Department of Urology, University of Michigan, Ann Arbor, Michigan.
Department of Urology, Henry Ford Hospital, Detroit, Michigan.
J Urol. 2021 Mar;205(3):833-840. doi: 10.1097/JU.0000000000001416. Epub 2020 Oct 9.
AUA guidelines recommend ureteroscopy as first line therapy for patients on anticoagulant or antiplatelet therapy and advocate using a ureteral access sheath. We examined practice patterns and unplanned health care use for these patients in Michigan.
Using the Michigan Urological Surgery Improvement Collaborative (MUSIC) clinical registry we identified ureteroscopy cases from 2016 to 2019. We assessed outcomes and adherence to guidelines based on therapy at time of ureteroscopy: 1) anticoagulant: continuous warfarin or novel oral agent therapy; 2) antiplatelet: continuous clopidogrel or aspirin therapy; 3) control: not on anticoagulant/antiplatelet therapy. We fit multivariate models to assess anticoagulant or antiplatelet therapy association with emergency department visits, hospitalization and ureteral access sheath use.
In total, 9,982 ureteroscopies were performed across 31 practices with 3.1% and 7.8% on anticoagulant and antiplatelet therapy, respectively. There were practice (0% to 21%) and surgeon (0% to 35%) variations in performing ureteroscopy on patients on anticoagulant/antiplatelet therapy regardless of volume. After adjusting for risk factors, anticoagulant or antiplatelet therapy was not associated with emergency department visits. Hospitalization rates in anticoagulant, antiplatelet and control groups were 4.3%, 5.5% and 3.2%, respectively, and significantly increased with antiplatelet therapy (OR 1.48, 95% CI 1.02-2.14). Practice-level ureteral access sheath use varied (23% to 100%) and was not associated with anticoagulant/antiplatelet therapy. Limitations include inability to risk stratify between type/dosage of anticoagulant/antiplatelet therapy.
We found practice-level and surgeon-level variation in performing ureteroscopy while on anticoagulant/antiplatelet therapy. Ureteroscopy on anticoagulant is safe. However, antiplatelet therapy increases the risk of hospitalization. Despite guideline recommendations, ureteral access sheath use is not associated with anticoagulant/antiplatelet therapy.
AUA 指南建议对接受抗凝或抗血小板治疗的患者行输尿管镜检查作为一线治疗，并提倡使用输尿管导入鞘。我们在密歇根州检查了这些患者的实践模式和非计划性医疗保健使用情况。
使用密歇根州泌尿科手术改进合作组织（MUSIC）临床登记处，我们从 2016 年至 2019 年确定了输尿管镜检查病例。我们根据输尿管镜检查时的治疗方法评估了结果和对指南的遵循情况：1）抗凝：持续华法林或新型口服药物治疗；2）抗血小板：持续氯吡格雷或阿司匹林治疗；3）对照：未接受抗凝/抗血小板治疗。我们拟合多变量模型，以评估抗凝或抗血小板治疗与急诊科就诊、住院和输尿管导入鞘使用的关系。
共有 31 家诊所的 9982 例输尿管镜检查，分别有 3.1%和 7.8%的患者接受抗凝和抗血小板治疗。无论手术量如何，在接受抗凝/抗血小板治疗的患者中，手术实践（0%至 21%）和外科医生（0%至 35%）都存在差异。在调整了风险因素后，抗凝或抗血小板治疗与急诊科就诊无关。抗凝、抗血小板和对照组的住院率分别为 4.3%、5.5%和 3.2%，抗血小板治疗显著增加（OR 1.48，95%CI 1.02-2.14）。实践层面输尿管导入鞘的使用存在差异（23%至 100%），但与抗凝/抗血小板治疗无关。局限性包括无法在抗凝/抗血小板治疗的类型/剂量之间进行风险分层。
我们发现，在接受抗凝/抗血小板治疗的患者中，手术实践和外科医生层面存在差异。抗凝治疗下进行输尿管镜检查是安全的。然而，抗血小板治疗会增加住院风险。尽管有指南建议，但输尿管导入鞘的使用与抗凝/抗血小板治疗无关。
